Medicare liner replacements

Medicare liner replacements

Laura Ramsower

10/5/2020

We are in Jurisdiction C. Medicare is denying all of our prosthetic liner replacements. In speaking with our MAC, they have told us that it is the results of an automatic claim edit where the liners are denied because they are not billed with a prosthetic base code. We have been advised to appeal all of the denials with medical records showing that the patient has received a prosthetic leg in the past and needs replacement liners due to a reason that shows medical necessity (along with an RX of course). We have done this and have submitted excellent physician notes showing continued use, medical necessity for replacement, etc. and the appeals are still denied. We are appealing at higher and higher levels, but are not having any luck getting them overturned.

We are at a loss as to how to get replacement liners covered by Medicare now that these claim edits have been put in place. Does anyone have any tips on how the claim needs to be processed (are we missing a modifier or something?) or what needs to be included in the medical records to have a slam-dunk in getting the denial overturned? Any input would be greatly appreciated.

I am happy to compile responses and email a follow-up - I am certain that we are not the only facility having this issue.

Thanks,
Laura


[cid: <Email Address Redacted> ]

Laura Ramsower, MSBME, CP, LP, LOA, CFm
Compliance Officer
Practice Manager

Mobile: 646-468-7531
Office: 512-445-0600 Ext. 1038
Fax: 512-912-9618
E-mail: <Email Address Redacted> <mailto:<Email Address Redacted>>

Medical Express PSI
1701 W. Ben White Blvd, Ste 162
Austin, TX 78704
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To report Compliance Violations: <Email Address Redacted> <mailto:<Email Address Redacted>> or send an anonymous fax to: 1-888-802-1251 (if reporting anonymously, provide enough details to be able to investigate)



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